Provider Demographics
NPI:1316352891
Name:BROCK, TRICIA
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 S HILL RD
Mailing Address - Street 2:
Mailing Address - City:VAN ETTEN
Mailing Address - State:NY
Mailing Address - Zip Code:14889-9711
Mailing Address - Country:US
Mailing Address - Phone:607-426-0298
Mailing Address - Fax:
Practice Address - Street 1:37 S HILL RD
Practice Address - Street 2:
Practice Address - City:VAN ETTEN
Practice Address - State:NY
Practice Address - Zip Code:14889-9711
Practice Address - Country:US
Practice Address - Phone:607-426-0298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist